1730238528 NPI number — MRS. JESSICA D SUNDAHL L.M.P

Table of content: MRS. JESSICA D SUNDAHL L.M.P (NPI 1730238528)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1730238528 NPI number — MRS. JESSICA D SUNDAHL L.M.P

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
SUNDAHL
Provider First Name:
JESSICA
Provider Middle Name:
D
Provider Name Prefix Text:
MRS.
Provider Name Suffix Text:
Provider Credential Text:
L.M.P
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
TISCH
Provider Other First Name:
JESSICA
Provider Other Middle Name:
D
Provider Other Name Prefix Text:
MS.
Provider Other Name Suffix Text:
Provider Other Credential Text:
L.M.P
Provider Other Last Name Type Code:
2

NPI Number Information

NPI Number:
1730238528
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
10/08/2013
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
4815 97TH ST E
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
TACOMA
Provider Business Mailing Address State Name:
WA
Provider Business Mailing Address Postal Code:
98446-5428
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
253-905-5214
Provider Business Mailing Address Fax Number:
253-503-6146

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
4111 S MERIDIAN
Provider Second Line Business Practice Location Address:
SUITE 208
Provider Business Practice Location Address City Name:
PUYALLUP
Provider Business Practice Location Address State Name:
WA
Provider Business Practice Location Address Postal Code:
98373-5973
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
253-905-5214
Provider Business Practice Location Address Fax Number:
253-503-6146
Provider Enumeration Date:
01/09/2007

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 225700000X , with the licence number:  MA00016460 , registered in the state of WA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 0158989 . This is a "LABOR AND INDUSTRIES" identifier , issued by the state of ( WA ) . This identifiers is of the category "OTHER".
  • Identifier: 6021925760010001 . This is a "UBI BUSINESS" identifier , issued by the state of ( WA ) . This identifiers is of the category "OTHER".
  • Identifier: MA00016460 . This is a "LICENSE FOR MASSAGE" identifier , issued by the state of ( WA ) . This identifiers is of the category "OTHER".
  • Identifier: 4342TI . This is a "REGENCECARE ID NUMBER" identifier , issued by the state of ( WA ) . This identifiers is of the category "OTHER".
  • Identifier: 254423100000 . This is a "PREMERA PROVIDER NUMBER" identifier , issued by the state of ( WA ) . This identifiers is of the category "OTHER".
  • Identifier: 0007827360 . This is a "AETNA PROVIDER NUMBER" identifier , issued by the state of ( WA ) . This identifiers is of the category "OTHER".




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